In October:

  • 2 cases of Wild Polio Virus (WPV1) were confirmed
  • Cross-borderteams and permanent transit teams (PTTs) vaccinated 78,286 and 520,208 children respectively

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During March, polio social mobilisers provided routine immunization referral services to over 37,000 children. ©UNICEF Afghanistan

In March 2020, polio social mobilisers from the UNICEF-run Immunization Communication Network (ICN) provided routine immunization referral services to over 37,000 children in southern and eastern Afghanistan.

The polio programme’s routine immunization efforts in Afghanistan have made important gains, especially in the country’s east, in the areas bordering Pakistan. Polio social mobilisers support mother and child health referral services, and help families keep track of their children’s health records. As the mobilisers are recruited from their community, they know the families in their neighborhood and can trace each child’s planned immunization schedule from birth.

It is critical that routine immunization continues throughout the pandemic to protect children from life-threatening diseases including polio. Polio mobilisers have found their work is even more valued during the COVID-19 response.

Masoud, a polio mobiliser, says ‘’I used to announce the immunization sessions through the Mosque but not all the targeted children were brought to the health facility. Now through the ICN support to routine immunization, the number of missed children has reduced due to tracking of every child in the community and coordinating with the health facility.”

“This is critical during the ongoing pandemic, as families are not sure if they can leave their homes to take their children to the health facility for immunization. The polio mobilisers are their guide in the community.’’

Polio workers hold up a banner during a 5-day campaign to vaccinate 2.6 million children in Kenya. ©WHO/Kenya
Polio workers hold up a banner during a 5-day campaign to vaccinate 2.6 million children in Kenya in July 2019. ©WHO/Kenya

Brazzaville, 19 December 2019 – Kenya, Mozambique and Niger have curbed polio outbreaks that erupted in different episodes over the past 24 months, World Health Organization (WHO) announced.

Transmission of vaccine-derived poliovirus was detected in the three countries in 2018, affecting 12 children. No other cases have since been detected.

“Ending outbreaks in the three countries is proof that the implementation of response activities and ensuring that three rounds of high-quality immunization campaigns are conducted can stop the remaining outbreaks in the region,” said Dr Modjirom Ndoutabe, Coordinator of the WHO-led polio outbreaks Rapid Response Team for the African Region.

“We are strongly encouraged by this achievement and determined in our efforts to see polio eradicated from the continent. It is a demonstration of the commitment by Governments, WHO and our partners to ensure that future generations live free of this debilitating virus,” added Dr Ndoutabe.

Vaccine-derived polioviruses are rare, but these viruses affect unimmunized and under-immunized populations living in areas with inadequate sanitation and low levels of polio immunization. When children are immunized with the oral polio vaccine, the attenuated vaccine virus replicates in their intestines for a short time to build up the needed immunity and is then excreted in the faeces into the environment where it can mutate. If polio immunization coverage remains low in a community and sanitation remains inadequate, the mutated viruses will be transmitted to susceptible populations, leading to emergence of vaccine-derived polioviruses.

No wild poliovirus has been detected anywhere in Africa since 2016. This stands in stark contrast to 1996, a year when wild poliovirus paralysed more than 75,000 children across every country on the continent. The WHO African Region however, is currently facing outbreaks of a rare poliovirus strain known as circulating vaccine derived poliovirus.

The work of the Rapid Response team starts once the lab confirms that a sample collected from either the environment or a paralysed child is caused by a poliovirus. Every minute that passes from then means that the virus is circulating and risks infecting more children that is why the Rapid Response Team deploys with 72 hours. The team supports local health authorities in the affected country in preparing the risk assessment and outbreak response plan. Then assist with launching the emergency response vaccination campaign, called round zero, within 14 days. A second team then takes over after the first eight weeks and continues the outbreak response activities including ensuring that three more rounds of high-quality vaccination campaigns are conducted.

To end outbreak activities in an affected country national and regional disease surveillance and laboratory teams need to confirm that no polio transmission is detected in samples collected from paralysed children, children in contact, and the environment have been negative for at least nine months. Response to the polio outbreak requires a strong multisector collaboration. In these efforts, WHO with other Global Polio Eradication Initiative spearheading partners: UNICEF, Rotary International, the US Centers for Diseases Control (CDC), the Bill and Melinda Gates Foundation (BMGF) and other stakeholders have been supporting the Government of Angola in implementing measures to end the transmission of the poliovirus.

Countries still experiencing outbreaks of vaccine-derived poliovirus in Africa are: Angola, Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Nigeria, Togo and Zambia. The risk factors for these outbreaks include weak routine vaccination coverage, vaccine refusal, difficult access to some locations and low-quality vaccination campaigns, which have made immunization of all children difficult.

Countries of the region experiencing outbreaks are continuing to implement outbreak response, following internationally-agreed guidelines and strengthening surveillance activities to rapidly detect any further cases.  To successfully implement the outbreak response required, the engagement of government authorities at all levels, civil society and the general population, is crucial to ensure that all children under the age of five are vaccinated against polio.

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A legion of supporters across neighbourhoods, schools, and households are creating a groundswell of support for one of the most successful and cost-effective health interventions in history: vaccination. These are everyday heroes in Pakistan’s fight against polio.

These thousands of brave individuals are championing polio vaccine within their communities to enlist the majority in the pursuit of protecting the minority — reaching the last 5% of missed children in Pakistan.

One of the major factors that determines whether a child will receive vaccinations is the primary caregiver’s receptiveness to immunization.  The decision to vaccinate is a complex interplay of various socio-cultural, religious, and political factors. By educating caregivers and answering their questions, these Vaccine Heroes serve as powerful advocates for vaccination, even creating demand where previously there might have been hesitation. This is where everyday people step in to vouch for vaccination as a basic health right.

Here are some nuanced, powerful, and thought-provoking testimonies on their unwavering belief in reaching every last child:

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In the last week of October, Djibouti’s Ministry of Health, working with WHO, UNICEF and other partners, successfully carried out the country’s first polio National Immunization Days (NIDs) since 2015.

A child being vaccinated at the NID launch in Djibouti. WHO/Djibouti
A child being vaccinated at the NID launch in Djibouti. © WHO/Djibouti

While Djibouti has not had a case of polio since 1999, the recent outbreaks of polio in neighbouring countries in the Horn of Africa, and the low levels of routine immunization coverage in some areas in the country, are indications that Djibouti is still at risk if poliovirus spreads through population movements. Other countries in the Horn of Africa are already cooperating to stop the ongoing outbreak and to reduce the risk of spread, and especially considering that Djibouti is on a major migration route in the Horn of Africa, it makes a lot of sense for Djibouti to join in this coordinated response.

For Dr Ahmed Zouiten, the acting WHO Representative (WR) in Djibouti, this context demanded action.

“I prefer to deal with a campaign for prevention than to have to deal with an outbreak of polio,” he said.

With that in mind, an NID planned for 2019 was brought forward and carried out over 23-26 October. The target was 120 000 children under five years of age, a number suggested by Djibouti’s last census, in 2009. Two strategies were proposed: one approach, where children would be vaccinated at fixed points (health facilities) and a complementary door-to-door approach using two-person teams (a vaccinator and a registration person).

In the days and weeks before the NID, all partners, including the government, WHO and UNICEF, used a variety of communication channels – from outdoor signage to radio spots – to ensure that communities were informed not just of the risks of polio, but also of the importance of protecting children from vaccine preventable diseases.

A mother and her child at the launch of the Djibouti NID. WHO/Djibouti
A mother and her child at the launch of the Djibouti NID. © WHO/Djibouti

The campaign’s official launch ceremony was held at the Youssouf Abdillahi Iftini Polyclinic in Balbala neighborhood, Djibouti City, in the presence of Djibouti’s Minister of Health, WHO and UNICEF representatives, and other partners. Over the course of the following days, vaccinators surpassed targets, vaccinating all children under five they encountered living on Djibouti territory, regardless of their origin, including nomadic populations, refugees and migrant children.

Although final numbers are still being tabulated through independent monitoring mechanisms, initial results suggest high coverage of the target population. This means vaccinators reached the estimated target number of children, and more, such as newer cohorts of children not accounted for in earlier estimates. Catching these children helps to further inform immunization estimates for any further campaigns.

For Dr Zouiten, a result like this is something to celebrate.

“Today, our children are on their way to being better protected, and we are launching a second campaign in the near future to follow up on that,” he said.

“Before, we had some worries; we thought that the circulation of poliovirus in the region posed a risk. Now with this first vaccination campaign, we know we are on the right path to ensure the children of Djibouti are protected. These results weren’t easy to achieve, but were made possible through collaboration between the Ministry of Health, the partnership between WHO, UNICEF and others.”

Given the high risk of importation of poliovirus, the Government of Djibouti, WHO and UNICEF are not taking any chances: plans are in the works for a second and third NID to roll out in 2019. With an outbreak in the region, it is critical for nearby countries to strengthen their own immunity levels and ensure routine immunization and disease surveillance systems are strong enough to detect any virus circulation. Despite the cost and effort of staging national immunization activities, in this case, all partners agree: an ounce of prevention really is worth a pound of outbreak response.

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Thanks to the efforts of Hauwa, a UNICEF community mobilizer, Nasiru has taken responsibility for ensuring that all his children receive their polio and other routine vaccinations. © UNICEF/Nigeria
Thanks to the efforts of Hauwa, a UNICEF community mobilizer, Nasiru has taken responsibility for ensuring that all his children receive their polio and other routine vaccinations. © UNICEF/Nigeria

“Please wait, I’ll soon be with you,” says Nasiru, the father of six children, as he disappears into his house in Gagi Makurdi settlement in Nigeria’s northwestern State of Sokoto.

Within minutes, Nasiru reappears, proudly displaying immunization cards with the record of the vaccines given to his youngest three children. It is unusual for fathers in this conservative part of Nigeria to readily know the whereabouts of these documents. Tending to children and ensuring that they stay healthy is usually a mother’s job.

“Take a look at the cards. My children Fidausi and Fatima have completed all their required immunization, whilst my youngest, Nana Asmaiu, is well on course to complete his,” he says.

Nasiru is a champion for immunization, but he wasn’t always so enthusiastic.

20 000 community mobilizers

It was Hauwa Ibrahim, a 46-year-old UNICEF-trained Volunteer Community Mobilizer, who persuaded Nasiru that the vaccine was safe and effective. She is part of a 20 000-strong network of community mobilizers who work across twelve Nigerian states like Sokoto, where some communities have been resistant to polio vaccination.

Hauwa inspects a baby’s vaccination card. By building up trusting relationships with her community, her health advice gains credibility. © UNICEF/Nigeria
Hauwa inspects a baby’s vaccination card. By building up trusting relationships with her community, her health advice gains credibility. © UNICEF/Nigeria

As recently as 2012, Nigeria used to account for half the world’s polio cases. Today, with help from women like Hauwa, no wild poliovirus has been detected in the country since August 2016. There are still many immunity gaps in Nigeria – as underlined by an outbreak of vaccine-derived virus currently ongoing in the country – but in the villages where VCMs like her work, these gaps are beginning to close.

Using a simple register, Hauwa goes house to house in Gagi Makurdi to record all children below the age of five, as well as women who are pregnant. It is the same register that Hauwa used to track the pregnancies of Nasiru’s wife – Zara’u – and she now uses it to find out who manages the routine immunization schedules of the three youngest children in the household.

Strengthening routine immunization

This forms part of the polio programme’s work in Nigeria to strengthening routine immunization, building on the infrastructure developed to eradicate the virus.

Upon her first visit, Hauwa was determined to convince Nasiru that vaccination against polio and other diseases is important – and that he should take the children to the health facility.

“My culture does not allow a wife to go outside of the compound, so when Hauwa insisted that we take our children to the health facility for vaccines, I had no way but to go myself. Else, Hauwa would not give up,” Nasiru explains. Whilst he travels with his children, Zara’u takes care of their older siblings at home.

By recruiting locally influential women like Hauwa from communities where some parents are vaccine-hesitant, and training them to be advocates for child health, vaccination rates are improved throughout their neighbourhoods. In some areas, more than 99% of parents now accept the polio vaccine for their child.

“Hauwa resides in this settlement and I trust her; I trust that the advice she is giving is in the best interest of my children,” says Nasiru.

He also notes, however, that he is often the only man at the health facility.

Engaging all fathers

Hauwa hopes that by encouraging more fathers to take on the parental responsibility of completing their children’s routine immunization schedule, immunization coverage will increase across Sokoto. Greater vaccine acceptance and awareness means that children are more likely to receive a life-saving polio vaccine, and other vaccines, whether through routine immunization or through door-to-door vaccination.

Already, the trust that she has built amongst parents in Gagi Makurdi has helped surmount many of the barriers that deny children immunization and other health services. In Nasiru and Zara’u’s compound, nearly all children are now protected against polio and other vaccine-preventable diseases.

Only their baby, Nana Asmaiu, has yet to have all his vaccinations – and Hauwa will soon visit his household to support Nasiru and Zara’u, and ensure he gets them.

Dr Adele Daleke Lisi Aluma speaks to Robert about the symptoms of measles, polio, and other vaccine-preventable diseases. His answers are recorded using a smartphone app, and transmitted to a central database. © WHO/ Darcy Levison

Nine hours away from the nearest large town, Dr Adele Daleke Lisi Aluma speaks to Robert, who manages a small health clinic on an island in the Lake Chad Basin. With paperwork spread around them, she listens carefully he responds to each question: Can you tell me how to recognise the symptoms of a potential polio case? Can you show me the records of any measles cases since I last visited?

In the past, she would be writing down details of the disease surveillance system in this village in a notebook, spending time later typing up her notes, and emailing them to a central database. Today, thanks to the introduction of an electronic surveillance approach for active surveillance and monitoring of disease outbreaks, she inputs Robert’s answers directly into an app, allowing for quick, accurate, and up-to-date data collection.

Hundreds of kilometres away in Nigeria, on the other side of the basin, surveillance officer Dr Namadi Lawal also feels the difference that innovative application-based technology has made to operations. For years, his employer, the National Primary Health Care Development Agency, depended on paper-based recording methods.

When the World Health Organization introduced the electronic surveillance (e-Surve) approach, Dr Namadi discovered he was receiving far more accurate information in real time, making his work to defeat the poliovirus more efficient.

“e-Surve is such a wonderful innovation. I can only imagine how much more accurate data I would have collected in a fast and effective manner if I had adopted this approach long time ago,” he says.

© WHO/ Darcy Levison
Using application-based technology, conversations with health workers in the field are guided by a simple questionnaire, which improves the quality and consistency of data collection. © WHO/ Darcy Levison

The e-Surve approach involves the use of a smartphone application to ensure that health workers know what symptoms they should be looking for and how to report suspected cases of vaccine-preventable disease.

After using the application to guide their conversations with health workers, disease surveillance and notification officers send the results of the questionnaire to a central database, where the data can be analysed and sorted by health district.

This is one way to keep track of an outbreak response that covers areas of five different countries, all with their own unique health challenges.

“This is remarkable progress as it shows where we can actually reach for surveillance”, said Dr Isaac Adewole, Nigeria’s Minister of Health, as he was presented with a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria.

New technology helps to reduce outbreak risk

This innovation is particularly important as when cases of disease are not properly reported, an outbreak can be in full swing before a country even realises that there is a problem.

Active disease surveillance, where officers physically go out to communities to speak to health staff and parents, is proven to increase case detection rates. There are hundreds of these frontline workers spread out across the Lake Chad Basin, each conducting multiple visits every month. Before mobile technology, the outcomes of these visits were cumbersome to track, time consuming to catalogue, and difficult to analyse for a prompt response.

Real-time reporting stems the spread of diseases

With e-Surve, governments and partners in the polio programme and other health programmes can easily see trends, track data, and take action. This encourages a preventive approach to disease outbreaks rather than a reactive one.

Dr Isaac Adewole, Nigeria’s Minister of Health, views a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria. With government commitment, the polio eradication programme is getting closer to closing the outbreak. © WHO/ AFRO

In Nigeria, as of May 2018, about 18 840 active surveillance visits to health facilities had been made using e-Surve technology: as a result, over 3000 suspected cases of vaccine-preventable diseases – previously unreported from health facilities – were identified and investigated.

 

Strong support from government 

Behind the new technology stands commitment from governments, communities, and partners to close the polio outbreak response. Dr. Sume Gerald at the WHO Nigeria office, states that “e-Surveillance in Nigeria is government-led and driven, supported by WHO.”

Through innovation, determination, and commitment at all levels, those working to end polio are getting ever closer to their goal.

Without the life changing impact of vaccines, our world would be a very different place indeed. © Anam Khan/WHO Pakistan
Without the life changing impact of vaccines, our world would be a very different place indeed. © Anam Khan/WHO Pakistan

Fear of paralysis, severe illness, or death from polio and smallpox was a very real and pervasive reality for people worldwide within living memory.

Ali Maow Maalin was the last person to develop smallpox, and later became an advocate for polio eradication. © WHO/John F. Wickett
Ali Maow Maalin was the last person to develop smallpox, and later became an advocate for polio eradication. © WHO/John F. Wickett

In 1977, the world was close to finally being smallpox free. The number of people infected had dwindled to only one man; a young hospital cook and health worker from Merca, Somalia named Ali Maaow Malin.

Before Ali, smallpox had affected the human population for three millennia, infecting the young, the old, the rich, the poor, the weak and the resilient.

Spread by a cough or sneeze, smallpox caused deadly rashes, lesions, high fevers and painful headaches – and  killed up to 30% of its victims, while leaving some of its survivors blind or disfigured.

An estimated 300 million people died from smallpox in the 20th century alone, and more than half a million died every year before the launch of the global eradication programme.

The power of a vaccine

Smallpox was declared eradicated in 1980, proof of the power of vaccines. © WHO
Smallpox was declared eradicated in 1980, proof of the power of vaccines. © WHO

Between 1967 and 1980, intensified global efforts to protect every child reduced cases of smallpox and increased global population immunity. Following Ali’s infection, the World Health Organization carefully monitored him and his contacts for two years, whilst maintaining high community vaccination rates to ensure that no more infection occurred.

Three years later, smallpox was officially declared the first disease to be eradicated. This was a breakthrough unlike any other – the first time humans had definitively beaten a disease.

But smallpox wasn’t the only deadly virus around

On March 26, 1953, Dr Jonas Salk announced that he had developed the first effective vaccine against polio. This news rippled quickly across the globe, leaving millions optimistic for an end to the debilitating virus.

Polio, like smallpox, was feared by communities worldwide. The virus attacks the nervous system and causes varying degrees of paralysis, and sometimes even death. Treatments were limited to painful physiotherapy or contraptions like the “iron lung,” which helped patients breathe if their lungs were affected.

Thanks to a safe, effective vaccine, children were finally able to gain protection from infection. In 1961, Albert Sabin pioneered the more easily administered oral polio vaccine, and in 1988, the Global Polio Eradication Initiative was launched, with the aim of reaching every child worldwide with polio vaccines. Today, more than 17 million people are walking, who would otherwise have been paralyzed. There remain only three countries – Afghanistan, Pakistan, and Nigeria – where the poliovirus continues to paralyze children. We are close to full eradication of the virus – in Pakistan cases have dropped from 35 000 each year to only eight in 2017.

Since there is no cure for polio, the infection can only be prevented through vaccinations. The polio vaccine, given multiple times, protects a child for life.

Better health for all

Thanks to vaccines, the broader global disease burden has dropped drastically, with an estimated 2.5 million lives saved every year from diphtheria, tetanus, pertussis (whooping cough), and measles. This has contributed to a reduction in child mortality by more than half since 1990. Thanks to an integrated approach to health, multiple childhood illnesses have also been prevented through the systematic administration of vitamin A drops during polio immunization activities.

Moreover, good health permeates into societies, communities, countries and beyond – some research suggesting that every dollar spent vaccinating yields an estimated US$ 44 in economic returns, by ensuring children grow up healthy and are able to reach their full potential.

Ali Maaow Malin, the last known man with smallpox, eventually made a full recovery. A lifelong advocate for vaccination, Ali went on to support polio eradication efforts – using vaccines to support better health for countless people.

Without the life changing impact of vaccines, our world would be a very different place indeed.

Vaccines ensure better health for all children. © Aman Khan/WHO Pakistan
Vaccines ensure better health for all children. © Aman Khan/WHO Pakistan
Zulaihatu Abdullahi, a volunteer community mobilizer in Kaduna State, goes door-to-door to ensure that every child is vaccinated against polio. © UNICEF Nigeria / Jasmine Pittenger
Zulaihatu Abdullahi, a volunteer community mobilizer in Kaduna State, goes door-to-door to ensure that every child is vaccinated against polio. © UNICEF Nigeria / Jasmine Pittenger

Zulaihatu Abdullahi is well known in her community, particularly to the mothers. As a volunteer community mobilizer in Kaduna state, northern Nigeria, her mission is to ensure that no child contracts polio, or any other preventable childhood disease.

This is difficult, as immunization programmes are sometimes treated with suspicion in her part of Nigeria. As a ‘change agent’, Zulaihatu’s job is to go door to door, counselling parents about the importance of the polio vaccine.

This particular lunchtime, she is visiting an 18 year-old mother living in a compound in a densely-populated, urban district of Kaduna State.

The young mother puts down the pole she is using to pound millet and welcomes Zulaihatu, recognising her royal-blue UNICEF hijab. She sits, and pulls on a hijab for cover as she settles down to breastfeed her baby. She has three other small children at home, a fifth on the way and she is new to the area.

“Before I came here I was rejecting all vaccines,” she says, “but because of this woman, Zulaihatu, I decided to accept. She told me the usefulness and I was convinced to do it.”

Thanks to Zulaihatu’s patience, and her work to build trust with the younger woman through regular visits, four more children are now protected against polio who might otherwise still be at risk. The mother has also been encouraged to seek anti-natal care, and the youngest child has just received his routine immunization shots.

“Sister Zulaihatu was one of the first women I met when we moved here,” the mother recalls. “She came here every day. She told me how she takes care of her own children. What she feeds them. How they all take vaccines. Little by little I started to change my thinking.”

Zulaihatu is trained to make her community aware of important household and parenting practices to keep their children thriving. The list is extensive and includes tips to treat diarrhoea, the importance of basic hygiene and sanitation, how to protect the family from malaria, the benefits of neonatal care and breastfeeding for infants, and the importance of registering their births.

She is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts spread across 14 northern ‘high risk’ Nigerian states. With the support of donor and partners including the Bill and Melinda Gates Foundation, CDC, Dangote Foundation, European Union, Rotary, GAVI, JICA, the World Bank and the Governments of Canada, Germany, Japan, and others, the mobilizers are a key part of UNICEF’s ongoing support to the Government of Nigeria’s immunization programme.

Despite their achievements, Zulaihatu and other mobilizers know that there is much is still left to be done in their communities. Tomorrow, Zulaihatu will continue her work, going from household to household to keep every child safe.

Zulaihatu is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts in Nigeria, who offer advice and support to parents to keep their children healthy. © UNICEF Nigeria / Jasmine Pittenger
Zulaihatu is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts in Nigeria, who offer advice and support to parents to keep their children healthy. © UNICEF Nigeria / Jasmine Pittenger

More stories about women on the frontlines of polio eradication

The discovery of wild poliovirus in Borno and Sokoto states in Nigeria in 2016 after more than two years without any reported cases prompted a multi-country response in neighbouring countries of the Lake Chad basin, covering Cameroon, Central Africa Republic, Chad, Niger and Nigeria. Since the outbreak response started, coordinated vaccination campaigns have been taking place in all five countries, reaching tens of millions of children. This year, campaigns are planned for March, April and October – all of them synchronized between the neighbouring countries.

In Chad, vaccination activities for polio and other diseases are being carried out in priority districts, supplementing regional campaigns which aim to target the hardest-to-reach children.

 

EPI Vaccinator Syed Mussayab Shah and Community Based Vaccinators, exchange information and data, at Civil Dispensary, Gulbahar, Peshawar. © UNICEF/Pakistan 2017/Kyinat Motla

“I feel our collective productivity has improved manifold, ever since we started working together with the Community Based Vaccinators from the polio eradication programme,” says Syed Mussayab Shah, a tone of pride in his voice. Shah is a vaccinator with the Expanded Programme of Immunization, posted at Gulbahar Civil Dispensary, Peshawar district, Khyber Pakhtunkhwa. He is responsible for immunizing children against nine vaccine-preventable childhood diseases.

Reaching children with vaccines in dense urban environments can be a significant challenge. So the polio eradication programme and the team responsible for delivering routine vaccines – the Expanded Programme on Immunization – are working together to make sure that they do the job as best they can, explains Shah. “We are determined to reach and vaccinate every child in our area. And to ensure this, we exchange information and notes with the community based vaccinators twice every week.”

“The synergy between the two programmes has been a blessing as we are reaching more children with vaccination every day, including those living in urban slums. Our spirits are high and we are determined to reach every last child.” Dr Akram Shah

Vaccination challenges in urban areas

Where families live in concrete housing units in urban slums, access to health care is a persistent challenge. The urban slums are often unrecognized, lack essential infrastructure and are low priority for local health authorities. This translates into low and unequitable coverage of social services in urban areas – including vaccination.

Pakistan is the most urbanized country in South Asia and the population living in urban slums continues to increase. The urban population has risen from an estimated 43 million in 1998 to 73 million in 2014. In Peshawar, increased migration is an additional challenge, making it the sixth biggest city in the country.

The challenge of identifying and vaccinating children living in urban areas, especially those living in slums and migrant families, is demanding innovation and skill sharing. The teamwork between the polio eradication team and the Expanded Programme for Immunization is ensuring everyone benefits – especially children who urgently need the protection offered by vaccines.

Increasing vaccination coverage through collaboration

EPI Vaccinator, administers vaccine to a child, Sikandar Town, Peshawar © UNICEF/ yinat Motla

The Civil Dispensary is the only government health facility in the area that caters not only to the residents of Gulbahar but also those living in adjoining slums. Community-based polio vaccinators from local areas come to this health facility to sit side by side with their colleagues from the broader vaccination programme to review their field books containing the housing maps and vaccination details of every single child under five in their areas. Microplans, containing this detailed information of local communities, are a valuable tool of the polio eradication programme. From this essential information, routine vaccinators make a list of unvaccinated children for follow-up who might be falling through the cracks. The polio vaccinators also refer clients from their communities to the health facility to receive their other routine vaccines. This collaboration is game changing for the drive to protect every last child against vaccine preventable disease.

 

UNICEF, with funding from Gavi, the Vaccine Alliance, is supporting the Government of Pakistan in improving routine immunization coverage in urban slums with a focus on seven major cities in Pakistan in collaboration with the polio eradication programme.Referring to the synergy initiative, Shah says, “Earlier we worked without defined plans and targets. Now, due to the information sharing from community based polio vaccinators, we have plans with identified areas and targets that help us monitor our own progress as well as the vaccination coverage.”

 

“Record keeping of families in urban slums is a very difficult job,” shares Tabassum Shuaib, a polio community-based vaccinator from Peera Gaib, Peshawar.

Teamwork paying off

“Families are constantly moving in and out from here – and many of those that move in do not have a vaccination card. They can only recall the number of times their child has been vaccinated. However, now I have all the families, pregnant mothers and children under five from this community registered and their data is maintained at the Gulbahar Civil Dispensary, so we can keep track ourselves and make sure no child is missed.”

EPI Vaccinators and CBVs refer to Routine Immunization Register during visit to an urban slum, Sikandar Town Peshawar. ©UNICEF/ Kyinat Motla
EPI Vaccinators and CBVs refer to Routine Immunization Register during visit to an urban slum, Sikandar Town Peshawar. ©UNICEF/ Kyinat Motla

Dr Akram Shah, Director of the Expanded Programme of Immunization in the area, is pleased with the rewards of this teamwork: “Peshawar offers the same challenges as any other major city of Pakistan. With increased migrant population and urbanization during the past decade, the burden of ensuring access to basic life and health resources to all has also increased. The synergy between the two programmes has been a blessing as we are reaching more children with vaccination every day, including those living in urban slums. Our spirits are high and we are determined to reach every last child.”

A mother helps to reduce outbreak risk by allowing her child to be immunized. © WHO
A mother helps to reduce outbreak risk by allowing her child to be immunized. © WHO

“I was told that if the child was vaccinated against polio, he could one day become a great footballer like Drogba and Yaya Toure…Today, they have not yet become like Drogba and Yaya, but they are in good health.”

– Awa B., mother of five children, Côte d’Ivoire

Today, the countries most vulnerable to poliovirus outbreaks are those where the barriers to effective immunization are most acute. In high-risk countries like the Central African Republic and Côte d’Ivoire, populations are hard to access and persuading communities of the need to vaccinate can be difficult.

For polio workers in these countries, it is important to reduce outbreak risk through strategies that involve local people, and which are receptive to the local surroundings and culture. Not every child will grow up to be a champion footballer, but by persuading parents of the importance of immunization, they can grow up active and healthy, protected from the debilitating effects of polio.

The risk of polio outbreak

The Central African Republic and Côte d’Ivoire are both considered outbreak risk countries due to their difficult political and security situations, weak health-care systems, and regular cross-border population movement.

Geographically close to Nigeria, one of the last three polio endemic countries, the Central African Republic is currently at risk of virus spread from Borno state where there was a poliovirus outbreak in 2016. In 2011, Côte d’Ivoire experienced an outbreak of wild poliovirus type 3, also originating from Nigeria.

A child is vaccinated against polio in the Central African Republic. November 2017 © UNICEF CAR
A child is vaccinated against polio in the Central African Republic. November 2017 © UNICEF CAR

Outbreak prevention is a central part of the strategy to end polio, as the spread of the poliovirus through under-immunized populations could make eradication more of a challenge. In high risk countries where delivering vaccine can be difficult, different methods must be used to comprehensively immunize every last child.

Getting the local community involved

In Côte d’Ivoire, a round of National Polio Vaccination Days officially began on October 28th in Ebimpé, marked by a ceremonial gathering of vaccination partners alongside key members of the local community. Speaking at the event, the Minister of Health and Public Hygiene, Dr Raymonde Goudou Coffie, described the need to vaccinate every last child as a mission for everyone: “Traditional leaders, heads of households and communities need to be involved in this initiative.”

This is a powerful method of engagement – making sure that parents and local leaders, as well as health workers and volunteer vaccinators, are involved in the fight against poliovirus.

No one approach fits all

Vaccinators also understand that no single approach will fit every situation. Instead, the Global Polio Eradication Initiative partners and field workers must work hard to understand how best to communicate the risk of polio outbreaks to different communities.

For instance, to reach parents working in Nana Mambere prefecture of the Central African Republic, local radio station SIRIRI hosted a panel based radio discussion to mark the recent vaccination campaign. Featuring medical professionals and local politicians, the panel addressed community worries around vaccine, urging every parent listening to take their young children to be immunized.

The day before the October campaign in Côte d’Ivoire, an advance team of volunteer vaccinators in Grand-Bassam began vaccinating at the local weekly market. Knowing the routine of local women, they anticipated that there would be some children visiting the market with their mothers who might not be reached later in the week – making this gathering of the community too good an opportunity to miss.

Health workers mobilize communities in Côte d’Ivoire, September 2017. © Rotary International
Health workers mobilize communities in Côte d’Ivoire. September 2017 © Rotary International

Having an understanding of the communities targeted in campaigns, whether of their worries around vaccination, or even parents’ weekly schedules, is crucial to effectively reduce the risk of a polio outbreak.

Providing broader benefits

In Côte d’Ivoire, Dr Bamba Souleymane, Departmental Director of Health in Grand-Bassam, noted the quantity of different health interventions that his team was attempting to successfully deliver. Alongside the polio vaccine, the volunteers were distributing impregnated mosquito nets, de-worming medication, and vitamins.

Such combined efforts use the GPEI’s well-established infrastructure to deliver a variety of desirable health benefits in communities, not polio vaccine alone. In places where the health infrastructure can be weak, the polio programme’s ability to reach remote children can be a big advantage for many reasons.

For Awa, the dream of her son becoming a champion footballer was a persuasive reason to take him to be vaccinated. For others, receiving different health benefits or hearing information via radio are compelling reasons to vaccinate their children.

Lowering the chance of an outbreak is never a straightforward process, but instead requires understanding parents, children, and communities.

The best vaccinators and campaign planners are able to spot opportunities to keep campaigns relevant, access groups in different ways, and ensure that coverage is sustained.

This way, we can successfully protect every last child.

More

Shokria, aged 4, displays her ink-stained finger to show that she has been vaccinated against polio. ©WHOEMRO 2016

In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.

Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.

Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.

Serosurveys testing for immunity

Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.

At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.

Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.

Serosurveys help to map where at-risk children are living. ©WHOEMRO 2016

For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”

High immunity in Afghanistan

The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.

These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.

Volunteer vaccinator Haji Mohammad inspects children from all over Kandahar, ensuring that no child is missed. ©WHOEMRO 2016

Using serosurveys in at-risk countries

As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.

By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.

This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.

Some children live in places that are harder to reach with polio vaccines than others. In every vulnerable country, the World Health Organization helps make sure that every child receives polio vaccines; even those who are on the move, living in conflict zones or in remote communities.

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Watch more in the polio eradication animation series

Young mothers waiting to vaccinate their children receive information on exclusive breastfeeding from a polio-funded Volunteer Community Mobilizer. @ UNICEF/R. Curtis

“Are you watching me?” “Yes, ma’am.”

“Are you seeing me?” “Yes ma’am.”

Along two rows of benches under the awning of the Chikun Primary Health Centre in northern Nigeria’s Kaduna State, about 50 young mothers sit still, their babies swaying on their laps. All eyes are fixed on Lidia, the assured polio social mobilizer who is not delivering polio vaccine, but showing the women how to correctly breastfeed.

Lidia is a grandmother, a one-time community midwife now employed with Nigeria’s polio eradication programme as a UNICEF-supported Volunteer Community Mobilizer (VCM). During the monthly polio vaccination campaigns, she goes house to house with the vaccination team, opening doors through her trusted relationship with the mothers, tackling refusals where they occur and tracking any children missed in the campaigns through her field book containing the names and ages of all children in her area. But it is between campaigns where Lidia’s full worth is realized.

Trust

Helen Jatau, a supervisor in this Local Government Area, supervises 50 VCMs and five first-level supervisors. She is convinced the health care polio frontline workers provide between campaigns provides benefits beyond the surface value – it establishes trust. “When we bring different things to the mothers, it helps the community live better and even accept us more, because we are giving more than just polio vaccines.”

Between polio vaccination campaigns, mobilizers like Lidia track pregnant women and ensure the mothers undertake four Ante-Natal Care visits, including immunization against tetanus. They advise mothers-to-be to give birth at the government health facility, provide them with the first dose of oral polio vaccine, facilitate birth registration and connect them to the routine immunization system. In houses and at monthly community meetings, the mobilizers also provide information on exclusive breastfeeding, hand washing, the benefits of Insecticide Treated Bed Nets, Routine Immunization and the polio vaccination campaign.

Ante-Natal Care

VCM Charity Ogwuche stands before the mothers at the health centre and peels over the pages of a colourful flip book. “Breastmilk builds the soldiers inside your child,” she shouts. “It will save you money. You don’t need to find food for your child to eat. You don’t need to find water: 80% of breastmilk is water. It will protect your child.”

Adiza, a young mother holding her first child, Musa, carries a routine immunization card including messaging on breast feeding and birth registration. “Aminatu talked to me about antenatal care. She asked me to get the tetanus shot, and today she has brought me here to receive routine immunization for my baby. I am really grateful. If she wasn’t here I wouldn’t be here. I wouldn’t know about it. She is the only one who tells me about this.”

Charity is proud of her work. “The women are so familiar with me, it makes me happy. They call me Aunty. I provide most of the health information for them. Really there is no other in our community. They are very young mothers and they need me.”

Birth registration

Aminatu Zubairu, in her trademark blue VCM shawl, displays the birth registration cards she will carry back to mothers in her village. @ UNICEF/R.Curtis

Every Tuesday is birth registration day. Once, hardly a soul turned up to register their newborns, but today, a long line of VCMs are standing clutching handfuls of registration forms, waiting to register the newborns within their catchment area.

Aminatu Zubairu, wrapped in the trademark blue hijab of the VCM, explains how all social mobilizers must come from their own community, and how that familiarity breeds the trust that has enabled her to register hundreds of children in her area. “I go to their houses and ask if they had the birth registration. If they say no I take all the information. Now I will register them and get the certificate of birth and carry it to their house to give back to them. In a month I can do 50 of these. This year there are plenty of newborns.”

Danboyi Juma, the district’s Birth Registration Officer, believes birth registrations have increased by 95% since VCMs assumed responsibility for the service. “They are helping us so much because they go house to house,” he says. “They have increased the number of birth registrations in this area by so much – oh, that’s sure.”

Routine Immunization

Jamila and her baby Arjera, who was vaccinated for the first time, following the persistent efforts of her VCM Rashida Murtala. @ UNICEF/R.Curtis

Despite stifling heat, on this Tuesday, there are more than 50 mothers and several fathers sitting on benches, waiting for their turn to have their babies vaccinated. More than 80% of them carry the cardboard cards given to them by VCMs to remind them their baby is scheduled for routine immunization.

Jamila, a young mother wrapped in a white shawl around her orange head-dress, is bringing her six-month-old baby Arjera to be vaccinated for the first time. Her VCM, Rashida Murtala, badgered her for months before Jamila finally accepted.

“Oh, she refused and refused,” Rashida says. “She’s fed up with me visiting. I went to see her today and finally she followed me. I’m happy to see her here.”

 

Jamila smiles. “She has been disturbing me every day that I have to take this child to the health centre. I know she’s right, so today I followed her.”

Priscilla Francis, the Routine Immunization provider who vaccinates young Arjera, believes VCMs are key to strong vaccination coverage in Chikun district. “There is much improvement in attendance since the VCMs started. They are well trained. They do a good job of informing mothers to come. If we lost them we would lose our clients – no doubt. When they come we tell them to come back, but no one else is going to their house to bring them.”

Hassana Ibrahim, a Volunteer Ward Supervisor, knows her mobilizers are important. “I have 10 VCMs, five in this ward. Non-compliance used to be a big problem but not now. Now with the routine immunization, the community sees they are providing a package of health care and now people comply with the polio vaccination.”

Naming ceremonies

New mother Naima with newly named Jibrin and her friends and family was happy to welcome her VCM to immunize children at her son’s naming ceremony: “She is my friend.” @ UNICEF/R.Curtis

Following the routine immunization session, the VCMs fan out to attend the naming ceremonies of newborns in their catchment area. Naming ceremonies provide an important opportunity to vaccinate lots of children, as family gathers around to celebrate. On average, they attend 10 naming ceremonies a month. Today we visit Naima, the young mother of a 7-day-old boy, who as per tradition has just been named Jibrin by his grandfather. Naima is surrounded by her sisters, family and village friends, who cook and eat with them, and their 68 children under five. Within minutes, the VCM has walked among them all, vaccinating them as they sit waiting with their mouths open to the sky like little birds.

Naima is happy to see her trusted VCM, and encourages her to vaccinate the children. “I know her well,” she says. “She taught me to go for ante-natal care, to deliver at the hospital and to go for immunization. She is the only health care worker who comes. We are from the same community. She is my friend.”

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